Application of Forrest Classifiction in the Risk Assessment and Prediction of Rebleeding in Patients with Bleeding Peptic Ulcer in Ado-Ekiti, Nigeria

摘要

Aim and Background: Peptic ulcer disease (PUD) is the most frequent cause of non variceal upper gastrointestinal tract bleeding. Rebleeding is a frequently observed complication of peptic ulcer bleeds. Recurrence of hemorrhage is one of the most important factors affecting the prognosis, and early prediction and treatment of rebleeding. The aim of this study was to assess if Forrest classification is still useful in the risk assessment and prediction of rebleeding after acute UGIB in Ado-Ekiti, Nigeria and to compare it with other results in literature.Materials and Methods: Fifty two consecutive patients who presented with clinical signs and symptoms of acute peptic ulcer bleeding between 1~(st) of January 2009 and 31~(st) of December 2011 were enrolled into the study. All underwent emergency endoscopy within 24 hours of admission. Forrest classification was used to categorize the various stigmata of active or recent bleeding seen at endoscopy. The study was carried out at the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria. An ethical clearance for this study was obtained from the institution’s Ethical and Research committee and all the patients gave written consent for the study. SPSS version 15.0 (SPSS, Inc., Chicago, Illinois, USA) was applied for statistical analysis using the t-test for quantitative variables and χ2 test for qualitative variables. Differences were considered to be statistically significant if P value was less than 0.05. Results: The mean age of the studied population was 53.92±12.14 years (age ranged from 29-78 years) while the female: male ratio was 1: 2.5. The presenting symptoms were; melena in 13.5% (7), haematemesis in 25% (13) and coexistence of both melena and haematemesis in 61.5% (32) of the patients. Findings at endoscopy were stratified using Forrest classification into: Forrest class IA; 3 (5.8%), Forrest class IB; 3 (5.8%), Forrest class IIA; 5 (9.6%), Forrest class IIB; 10 (19.2%), Forrest class IIC; 13 (25%) and Forrest class III; 18(34.6%). Rebleeding was found after initial stabilization and cessation of bleeding in 33.3% of those in Forrest class IA, 66.7% in Forrest class IB and 80.0% in Forrest class IIA. No rebleeding was found in the other classes. 30.8% of the patients had more than 4 pints of blood transfusion, 36.5% had 4 pints of blood, 23.1% had 3 pints of blood and 9.6% had 2 pints of blood.In the Univariate analysis, Forrest class was statistically significant to the occurrence of rebleeding (χ2 = 91.135, p = 0.001, α = 0.005 i.e. 95% confidence interval). Also, blood transfusion was found to be statistically significant to the severity of symptoms (χ2 = 17.979, p = 0.006, α = 0.005, i.e. 95% confidence interval). Conclusions: This study demonstrates that Forrest classification is still useful in predicting rebleeding of peptic ulcers; however, it does not predict mortality arising from UGIB. It is recommended that patients with UGIB be referred to centres with endoscopy facilities for initial assessment using Forrest classification to predict the risk of rebleeding and the need for urgent interventions as major bleeding episodes can be fatal for the high risk patients. This study is limited by the number of patients studied; hence a multicentre study is advocated to validate the conclusion made in this study in Nigeria.